MEDICARE: LYDIA HAUREZ LPC-MHSP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor	5834	TN

General Provider Information

NPI Number	:	1811645930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LYDIA HAUREZ LPC-MHSP

Provider Business Mailing Address
First Line	:	1709 MIAMI DR
Second Line	:
City	:	JOHNSON CITY
State	:	TN
Zip	:	37601-7542
Country	:	US
Telephone Number	:	765-413-0627
Fax Number	:

Provider Business Practice Location Address
First Line	:	1201 N WILCOX DR STE C
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37660-4986
Country	:	US
Telephone Number	:	423-225-3757
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2022
Last Update Date	:	10/10/2023

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